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SAN OAQUIN LOCAL HEALTH DI�RICT <br /> NDERGR <br /> U5TORAGE TANK PROGRAM FARM TANK INFORMA FORM <br /> FACILITYISITE INFORMATION (Complete thea Fon for each FARM TANK location) r <br /> FARM or BUSINESS NAME CONTACT NAME <br /> F NOV 1 0 2003 <br /> A <br /> C ADDRESS (Street addresl of TANK location) PHONE 1 WITH "CA CCOa <br /> ENVIRONME(V N <br /> ZSc`62 E- i PERMIT/StrViL'ILS <br /> T CITY STATE 11P CODENEAREST CROSS STREET <br /> Y C C- <br /> C Q 0-n 4 7 <br /> CMECC HERE if this ADDRESS should be used for Legal Notification <br /> OPERATOR INFORMATION I ADDRESS (Complete If Information Different from Above) <br /> NAME OPERATOR CONTACT NAME <br /> 0 <br /> P <br /> E MAILING or STREET ADDRESS OPERATOR PHONE 1 WITH AAKA COOK <br /> R <br /> A <br /> T <br /> O CITY STATE IIP CODE <br /> R <br /> CMECI 1EIE if this ADDRESS should be used for Legal Notification <br /> PROPERIY OWNER INFORMATION I ADDRESS (Complete If Different from Above) <br /> NAME OWNER CONTACT NAME <br /> 1 a <br /> 0 MAILING or STREET ADDRESS OWNER PHONE 1 WITH AACA COOK <br /> W <br /> " 5 c i <br /> F. <br /> R CITY STATE ZIP CODE <br /> cra 9 on G41} -ZID <br /> CHECK ME IE if this ADDRESS should be used for Legal Notification <br /> CAect AAAraArlafe toy <br /> I ACTIVE FARM TANK SITE (One or more underground TANKS ) 11100 gal. capacity) <br /> Y <br /> P EXEMPT FARM TANK SITE (ALL underground TANKS at site K to or ( 11100 gal. capacity) <br /> E <br /> PERMANENTLY CLOSED FARM TANK SITE (ALL underground TANKS at site removed or closed in place) <br /> UNOERSROUNO TANK INFORMATION (List Additional tank information on separate sheet if needed) <br /> I TANK SIIE CHEMICALS STORED ESTIMATED DATE LAST USED METHOD OF CLOSURE DATE OF EMOVA OR <br /> A (GALLONS) CURRENTLY OR PREVIGUSLY IF CURRENTLY EMPTY IF PERMANENTLY CLOSED CLOSURE ACE <br /> H <br /> K <br /> I <br /> H <br /> F <br /> 0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AMO CORRECT <br /> MANE TITLE OA1E <br /> II 4 <br /> OFfIEE 1f my <br /> SWEEPS 1 COMP 1 LOC CODE GIST CODE 1 ACTIVE UGT 1 EXEMPT UGT 1 CLOSED UGT SWEEPS PRGMISUB CODE DATE <br /> EN 23 044 (12188) <br />